endocrinology finals Flashcards
What are the 4 Diagnostic criteria for DM?
- H1C >= 6.5%
- fasting glucose >= 126
- glucose 2h after loading dose >= 200
- glucose >=200 in rendom test + glucose symptoms
- serum glucose need to be confirm with another test in a different day
- dont check during stress / ilness
What is the A1C target in DM
and what is the glucose level target
- A1C < 7% (under 6% found to be danger in high risk CV pt)
- Glucose level- between 70-180 (fasting glucose 70-130, 2h after meal 180)
3 main side effect of metformin
- Lactic acidosis (metabolic acidosis)»_space; need to reduce dose in CKD
- B12 def.
- GI upset- neuasa, vomiting, diarrhea
Weight loss
C/I for mteformin
- kisney failure (GFR < 30)
- HF
- Lung failure
- other organs failure
- Systemic ilness or shock
- during IV contrast imaging / major surgery and 48 hrs later
Which DM medications can casue hypoglycemia
- Sulfanulurea
- Glinides
- insulin
C/I for glucosidase inhibitors + sulfanylurea + Glinides
Renal /liver insuff.
Exp. repglinides- clearne only from liver
GLP-1 side effects
pancreatitis
Execpt- Exenatide
DDP-4 inhibitors side effect
gliptins
increase risk for Nasopharyngitis and URTI
Which diseases are C/I for the use of GLP-1
MEN
or
Medullary thyroid carcinoma
Can increase the prevalnce of Medullary thyroid carcinoma
Which DM medication can asue Urticaria / angioedema and immune mediated dermatological effect
DDP4inhibitors
nall of the following are cheracteristics of the DM medication——
Amylin analog, can be use in DM type I and II, loss weight, reduce hyperglycemia after food
Pramlinitide
may cause after meal (postprandial hypoglycemia)
which DM medication is beneficial in Pt with Renal disease
Thiazolidinediones
Gliterzone suffix
What is the C/I for Thiazolidinediones
- NYHA III-IV HF
may exacerbate CHF
What are possible Side effect using Thiazolidinediones
- Reduce bone density
- Weight gain
- excacerbate CHF
what is the MOA of alpha-glucosidase inhibitors?
Acrebose
inhibition of absorbtion of glucose by the intestine
combine with drugs like sulfnyl- can cause hypoglycemia
True or false?
SGLT2i lower episodes of CV event and reccurent hospitalization of CHF
TRUE
also reduce risk for diabetic nephropathy
Which DM drug can increase the risk for Euglycemic DKA
SGLT2i
glucose < 200
C/I for SGLT2i
Renal insuff. (not strat if GFR < 45, no use at all if GFR < 30)
Which DM medication does not effect at all on weight?
DPP4i
Which DM medication can be given in hepatic failure?
Intecrines (GLP-1, DPP4i), SGLT2i
Which DM medication can not be given in HF?
Metformin
TZD (Gliterzone)
How to confirm DKA Dx?
- hyperglycemia
- Eleveted Serum beta-hydrocybutarate
- Metabolic acidosis
What is the first Tx of DKA?
Fluid replacement:
2-3 L of normal seline or Ringers over first 1-3h
when blood glucose reach to 250 change to 5% glucose and 0.45% seline (prevent hyperchloremic acidodsis)
How to start insulin in DKA, and when to halt the Tx in insulin
insulin- 0.1 units/Kg per hour (increase 2-3 folds if no response after 2-4h)
halt when K levels < 3.3- od not administer insulin until pottasium is corrected
Which electrolyte disbalance DKA tx can cause?
all the Hypo:
* K
* Mg
* P
In which levels of Potassium in DKA a K will be added to the infusion?
K < 5-5.2
When we will Treat with HCO3 in DKA?
**only in Exterme acidosis PH < 7 **
What is the main Tx for HHS?
Fluid replacment
החזרת נפח נוזלים
True or false?
יש קשר סיבתי ברור בין היפרגליקמיה כרונית להיווצרות סיבוכים מאקרווסקולרים?
False
הקשר הסיבתי בהיפרגליקמיה היא עם סיבוכים מיקרווסקולרים ולא מאקרו
Which vaccination are recommended to all DM pt?
Influenza
Covid
Pneumoccoc
Whats the target in DM pt regarding their:
LDL , HDL levels
TG
BP
LDL < 100, < 70- if CHF or 2 CV risk
HDL ~40-50
TG < 150
BP- like general population (140/90) if theres CV risk (130/80)
What is the most common reason for ESRD in the develop world
Diabetic nephropathy
DM
How many DM pt will develop nephropathy?
and what is the % correlation between nepropthy to retinopathy
20%-40% will develop nephropathy
correlation:
DM1- 90%
DM2- 60%
What is a major risk factor for developing Diabetic nephropathy?
microalbuminurea (30-300)
50% of them will develop macroalbuminurea (>300)
50% of them will progress to CKD to ESRD
What is the first Tx when DM pt present with albuminurea?
ACEi / ARBS
if C/I then :
diuretics, CCB (non-dhydro = Verpamil/ dilitazem) or BB
if persist:
MRA
DM2»_space; SGLT2i
Reccurent episodes of hypoglycemic events in DM pt can lead to———
Hypoglycemia associated autonomic failure
damage the counter regulation of glucose (less glucagon when hypo, and less epinephrine)
decrease in awarness to hypo event
can be reverseble if hypo is prevent for 2-3 weeks
What is the cumaltive risk for pregnent women with gastetional Diabetic to develop DM?
risk of 60% in the following 10-20 years
screening recommended every 3 yrs for womens after Gs .diabetic
What is the most common reason for Cushing syndrome?
Steroid therapy
whats the different between Cushing disease to syndrome
Cushing disease is a sub-type of cushing syndrome where theres acess ACTH release from a pituatery adenoma
most common Endogenous reason for cushing
Which test can be done to check if cushing is ACTH-dependent vs. independent.
and what will be the further test based on the reasults
Check for ACTH levels
High/ normal ACTH- dependent»_space; Hypopyseal MRI
Low ACTH- independent»_space; Adrenals CT
How many of the tumors are being missed by MRI of the adrenals?
40%
which test could diff. between pituatery adenoma to Ectopic ACTH (like SCLC)
High dose Dexamethasome test (8mg)
if ACTH supress»_space; Adenoma
If ACTH remain High»_space; Ectopic source
What is the main reasons for Hyperaldo?
- primary hyperaldo:
- 60% Bilateral micronodular hyperplasia
- 40% Conn’s syndrome (unilateral adenoma)
also rare- Glucocorticoid-remediable hyperaldo- regulate system on aldosterone is by ACTH and not RASS
Which medication should be stop before performing Aldo-renin ratio test?
- Aldactone - after 4 wks w/o
- correction of hypokalemia
- consider- stopping beta-blockers for 2 wks (may cause FP)
What is the tests preform in suspicion of hyper-aldo?
- Aldo-renin ratio
- confirmation test- supress test by seline ingusion/ oral Na loading, fludrocortisone suppresion
- non Contract CT of adrenals
Which medication are elevate and which depress the ratio between Aldo-renin
Beta-blocker- elevate ratio
ACEi + ARB’s- decrease ratio
Which workup is rq after incedintiloma > 1 cm?
Encodrine workup include:
1. Metanephrins
2. screening for kushing (1st test Dexamethasone test)
3. Renin aldosterone ratio- if HTN present
4. Sex hormones if lesion > 4 cm
sex hormones: 17-hydroxyprogesterone, andriostenedione, DHEAS
When we will operate icidentally discovered adrenal mass
Hormonal activity
Malignancy
what are the 2 finding in imaging that have high suspicion for adrenal malignancy?
- size > 4 cm
- Density > 20 HU
What are the main Cherecters of primary adrenal insuff.
Think about which hormones will be defficient
- Hyperpigmentation- high levels of ACTH
- Aldosterone def.- acidosis, hyperkalemia, salt wasting type (hyponathremia) + hypovolemia
- Cortisol def.- Weight loss, fatigue, GI symptoms, hypoglycemia, postural hypotension
problem producing Aldo + Cortisol
What is the most common primary and secondary adrenal insuff
primary- Addison (autoimmune disease)
Secondary- Steroid medications
Which melanoma medication can cause Secondary Adrenal insuff
Anti-CTLA4 (ipilimumab)
causes hypopyseal autoimmune disease
How we diagnose adrenal insuff. ?
until the step of primary vs secondary
whats the steps in the algorithm
- Sinacten test (ACTH analog)- if Adrenal insuff. present > 4 wks cortisol will not elevate.
- Determine if primary or secondary- plama ACTH, Renin aldosterone ratio
Always Check for TSH- hypothyroidism can be a reason for hypoaldo
what is the famous triad of pheochromocytoma
Palpitation
headache
sweating
During surgery of pheochromocytome
how do we stabilize BP?
when it drop or elevated?
elevated- Nitroprussid
Drop- fluids IV
what is the most coomon reason for Thyrotoxicosis
Grave’s disease
Which Ab can be found in Grave’s disease
Thyroid stimulation immunoglobulins (TSI)
also called TRAb (TSH receptor Ab)
Which other Ab can be found in graves , which will not cause a disease
anti-TPO
anti- TG
all the following can lead to a high suspicious of ————- disease
Pre-tibial edema, purple -red plaques
exophtalmus
Grave’s disease
Which severe side effect can Mathimazole and PTU can cause
Vasculitis
Agrnulocytosis
How much time after Tx with Anti-thytoid medication we will see remission in Grave’s disease
12-18 months for max remission
What are the main indications for PTU and why?
- 1st trimester of pregnanct
- thyroid storm
- can’t tolerate mathmizole
Beacute PTU is heptotoxicity
What is the general stages when Tx in reactive Iodine (I131) is preform?
- start anti-thyroid Tx for a month
- few days begore ablation Tx stop medication
- procced with iodine reactive therapy
Which Biologic Tx is indicated for opthalmology by thyrotoxicosis
Teprotumumab
for proptosis, diplopia, functioning
Whats the Tx for Thyroid storm
ICU
high dose of PTU, KI, proprenolol
sometimes add Hydrocortisone
What are the reasons for sub-acute thyroiditis?
- viral(or granulamtous) - influenza, covid, adenovirus
- Silent - including postpartum
- Mycobacterial inf.
- drug induce- amiodarone, interferone
which tyroid condition is present with large and pain thyroid gland?
Subacute Thyroiditis
What will be the ratio of T4/T3 + ESR in sub-acute thyroiditis
high ratio T4/T3
+
Eleveted ESR and < 5% of radioactive iodine
Tx for sub-acute thyroiditis?
- Aspirin/ NSAIDS
second line
Steroids for 6-8 wks
Which Ab will be present in postpartum thyoridits
+
ESR levels
+
size and painful/ non painful gland
- anti TPO
- low ESR (sub-acute = high)
- painless / silent
when amiodarone will cause hypothyroidisem
if theres an autoimmune disease of hypo (in base) like hasimoto- then there will be no escape from the wolf chaikoff affect
will not stop Amiodarone, just add levothyroxine
What are the 2 main types of amiodarone induces thyrotoxicosis?
and whats the main diff. bewteen them
Type I (AIT)- pt wth pre-disposition for thyroid disease ( Grave’s / MNG)»_space; more iodine will lead to more thyroid hormones
Type II- no pre-disposition. destructive thtrotoxicosis
How to diff. between AIT type I and II
and whatsthe Tx?
colour doppler
High vasculativity»_space; Type I
**stop amiodarone **
- Type I Tx- High dose Anti-thyorid + K-percholate (can cause Agranulocytosis)
- Type II Tx- prednisone + lithum»_space; Thyrodectomy (most effective long term )
What will be the following levels in Factitious thyrotoxicosis?
Tg (thyroglobulin)
T4
TSH
low Tg
low TSH
high T4
קליטה נמוכה בבדיקת יוד
Whats the Tx of choice for Toxic thyroid adenoma
יוד רדיואקטיבי- מצטבר באדנומה (טיפול דפיניטיבי)
What is the DDx for
low T3 (with T4 + TSH normal)
high rT3- Euthyroid sick syndrome
low rT3- central hypothyroidisem
When we will Treat Sub-clinical Hypothyroidism
(high TSH, normal T4, asymptomatic)
- TSH > 10 + anti-TPO
- pregnancy or planning pregnancy
- heart disease
if we not treat- follow up 1X year
Euthyroid sick syndrome
Tx?
Monitoring
What is Myxedema coma?
% of death?
prevelance age?
Acute and exterme hypothyroiditis
- 20-40% dath
- most common in elderly
Tx of myxedema coma
- LT4 IV
- consider adding T3 for inital Tx
- Hydrocortisone
- heating when Tm < 30
- Treat the Triger!!
What are the indication of radioactive iodine ablation
Toxciv adenoma
MNG
Graves
adv. carcinomas
always treat before with anti-thyroid medication and stop few days prior the procedure
Thyroid tumors
Whats the Tx for tumors > 4 cm
near total thyroidectomy + ablation by radioactive iodine
Which marker is used to asses residual disease or reccurent of thyroid cancer? (after total thyroidectomy and ablation)
Thyroglobulin
+
Neck US for LN 6 month after ablation
most reccurence will be at cervical LN
Which elecctrolyte disturbance Def. in Vitamin D can cause?
Hypocalcemia
Hypophosphatemia
Hypomagnesemia
איזה סוג של שומן משקף היקף המותניים?
והיכן נמדד
שומן ויסצרלי
measure above the iliac crest (less reliable then MRI/CT)
What is the definition of metabolic syndrome
at least 3 of the following
1. היקף מותניים- גברים > 102, נשים > 88 ס”מ
2. TG > 150
3. HDL- גברים < 40, נשים < 50
4. BP > = 130/85
5. Fasting glucose >= 100 / present of DM
What is the indication for briatric surgery?
BMI >= 35 + risk factors
BMI >= 40
Goal- reduction in 10-8% in 6 months
Definition of Osteoporosis
and what is the main clinical presentation
Definition
T score <= -2.5
main clinical presentation
vertebral and hip fractures
T- score- ביחס לממוצע מבוגרים בריאים צעירים מאותו מין ומוצא
True / false
PPI increase the risk for osteoporosis
True
also: steroids, Cyclosporins, anti-epileptic, aromatase inhibitors, SSRI, lithum, TZD
Who will be check for bone density?
- every women > 65 , post-menopausal, during menopausal
- every males > 70 or 50-69 with clinical risk for fracture
- fracture in age 50
- מבוגרים על מחלות רקע שנוטלים תרופות המקושרות למסת עצם נמוכה (למשל פרדניזון 3 חודשים)
Which supplaments and medications will be given to a pt with osteoporosis?
- calcium- 1000 mg < 50 > 1200 mg.
- Vitamin D- 1000-2000IU
**only ** Vitamin D + Calcium toghther will reduce the risk for fractures
Calcium alone can reduce the risk for fracture but in a lesser extent then when combined with vitamin D
What is the recommendation of vitamin D supplementation?
general population with < 20 - 200IU < age 50 > 400 < 70 > 600IU
What is the main indication (and when we should consider also) Pharmacological Tx in osteoporosis and osteoporosis related conditions
main indication- fracture from minor trauma + low bone density T < -1
also consider when
1. Osteoporosis (T < -2.5)
2. post-menopausal with fracture
3. risk > 20% for major fracture and > 3% for hip fracture in 10 years
Which medication from the antiresoptive agents are approved for osteoporosis/ reduce risk fracture?
5 agents
antiresoptive agents- prevent bone reabsorption
- Astrogen
- SERM ( Raloxifen- also breast cancer)
- Bi-phosphonate (Dronate suffix)
- Denosumab
- Calcitonin
Which medication from the anabolic agents are approved for osteoporosis/ reduce risk fracture?
PTH analoges
osteoporosis
which womens will take Astogens and which SERMS
what is the reduction risk in fracture?
Astorgens- women who start early after entering menopause, Fructure reduction in 50%, a bit elevation in bone mass
SERM- Rloxifene, for womens post-memopausal < 70 age (risk for DVT and storke in older) reduction in cervical vertebra 30-50%
Which medication is the mainstream in osteoporosis Tx?
What is C/I
main prons
posibble side effect
Bi-phosphonates (Dronate suffix)
C/I - GFR < 35
main prons- reduce incidence of fractures (incluse cervical and hip)
Side effect- Esophagitis, Osteonecrosis of jaw, skin infection, hypocalcemia, atipical fracture of femur
What is the MOA of Denosumab
Ab inhibit RANKL on osteoclasts
S.E- osteonecrosis of jaw, hypocalcemia and skin inf.
What is Teriparatide
analog for PTH
the leters:
PARATIDE like para-thyroid
Which type of bone trabecular / cortical is damage more in osteoporosis secondary to steroid therapy?
Trabecular
Osteoporosis secondary to steroids therapy
True or false:
1. osteoporosis is mainly when steroids are given IV
2. below 20 mg a day showed reduce risk
3. women and elderly are at higher risk
- false- can happen in any form of administration
- false- there’s no safe dosage, neither day in day out help.
- true
How does steroids affect the bones
inhibit osteoblasts
more bone reabsopbation, less Ca is reabsorb in the intestine, low sex hormones production in gonads and adrenal
What is the changes seen in electrolytes in bone in the abscent of Vitamin D?
- Hypocaclemia
- Hypomagnesemia
- hypophosphatemia
- elevate ALKP
- Proximal myopathy
- Osteopenia
How does high phosphor levels will affect:
PTH
FGF23
1,25-vit D
PTH- elevate = more phosphor will secrete by the kidney’s
FGF23- elevate = secrete phsphore in urine and low secrete of active vit-D
1,25 D- decrease = by FGF23 + High phosphor
Phosphor is secreted in PCT (part of fanconi syn.)
What are the 5 main mechanisms of low phosphor
- Decrese absorbtion in kideny- PTHrP, hyperPTH (primary), hypomagnesemia, alcholoism, high dose steroids
- Decrease absorbtion in the intestine
- Cell shift (similar to K)- Refeeding synd- hypo K, Po, Mg , B1, insulin Tx in DKA pt, fast prolifration of cells , Gram negetive sepsis
- Fast bone production- after para-thyroidectomy, osteoblast metastasis
- tumor induce osteomalacia- tumors that secrete FGF23
Which severe effect can hypophosphatemia can cause if happend rapidly
Rhabdomyolysis
Respiratory failure
Hemolysis
Tx for Hypophoshatemia for:
Severe < 2
mild
severe < 2
Phosphor IV , must correct Ca level prior
C/I- low Ca levels (Po will bind Ca and worsen hypocalcemia
Mild- Phosphor PO
What are the main causes of hyperphosphatemia?
- impaired renal excretion- hypo PTH or renal insufficeny
- Para-thyroid supression (like sarcoidosis (hypercalcemia)
- TLS, rhabdomyolysis…
What is the main cause of hyper Mg?
Renal insuff.
also:
GI loss - diarrhea
Pancreatitis
Renal losses- loop + thizide diuretics
Alchol abuse
Omeprazole - PPI
Foscarnet- anti-viral
Hyperaldostronism
similar to Ca- in bone, similar to K- in cell shift and kidney
Hypomagnesemia can lead to which Electrolyte abnormalitiy
low Mg:
PTH release »_space; raise mg to normal
very low Mg:
inhibit PTH release»_space; hypocalcemia
hypokalemia- Mg inhibit ROMK excretion (collecting duct)
K wont be corrected until Mg be corrected
What is the most common cause of hypercalcemia?
hyper PTH
malignancy
in 90% of cases
What is the cause of familial hypocalciuric hypercalcemia
AD, mut in CaSR - does not sense Ca»_space; PTH elevetion»_space; active vit. D elevation»_space; more Ca absorbation.
High plasma Ca + low urine Ca
mostly mild and a-symptomatic
Which malignancy can secrete PTHrP
and what is the most prognostic factor for hypercalcemia
Lung SCC
RCC
המנבא העיקרי הינו סוג הגידול ופחות התפשטותו לעצמות
how Lithum affect the Ca levels?
inhibit the sensetivity of Para-thyroid for Ca = elevete PTH + Hypercalcemia
(like FHH)
Hypercalcemia mnemonics
Stones, Bones, Groans (GI- anorexia, constipation, peptic ulcers, nausa) and psychiatrc tones
how hypercalcemia will be seen on ECG
short QT
+
elevetion in ST in V1-V3
Tx for hypercalcemia:
Ca < 12
Ca 13-15
Ca > 15
- Ca < 12- Hydration
- Ca 13-15- agressive hydration + consider other treatments
- Ca > 15- first 0.9% Hydration until normelize volumic status»_space; after fusid+ consider bi-phosphonates
also consider- Calictonin
Dialysis- in extereme pt.
Steroids- malignancy, excess vitamin D, sarcoidosis
Most common cause of primary Hyper PTH
isolated adenoma in para-thyroid
(6-10% of cases can be extra-thyroid)
eleveted Ca, PTH, decrease phosphor
What are the 7 indication for surgery in a-symptomatic pt with primary hyper-para thyroid
Think: Renal, Skeletal, Age
Renal
* Ca levels > 1 of NUL
* Creatinit Clearence < 60
* Ca in urine > 400 mg/day
* nephrolitiasis /nephrocalcinosis
Skeletal
* Bone density T-score < -2.5
* vertebra fractue
Age
* Age < 50
What is the first step in Hypocalcemic pt?
and why we do it
**Repair Calcium levels by albumin **
added calcium = 0.8 X (1 gram of albumin under 4)
do it to rule out psuedohypocalcemia
How chronic hypocalcemia will effect digoxin?
Decrease effectivness
Which are the 2 situation when theres Hypocalcemia + hypophosphpira
Vit. D deff.
+
Hypomagnesemia
